Objective: Prevalence of asymptomatic deep vein thrombosis (DVT) in patients with primary varicose veins remains unclear.Materials and Methods: Here, we conducted a retrospective study to clarify the incidence of asymptomatic DVT in patients with varicose veins, especially focusing on those with superficial thrombophlebitis (STP).Results: Among 431 patients with primary varicose veins with saphenous vein incompetence, 20 (4.64%) had asymptomatic DVT. The presence of STP was a significant risk factor for asymptomatic DVT as 10 of the 24 (41.7%) patients with STP had asymptomatic DVT, and all cases having calf muscle vein thrombosis. In contrast, of the patients with primary varicose veins without STP only 2.46% had asymptomatic DVT.Conclusions: In patients with primary varicose veins with STP, significant risk factors for DVT were being over C3 on the clinical, etiological, anatomical, and pathophysiological (CEAP) classification. (This article is a translation of Jpn J Phlebol 2014; 25: 13–19.)
We investigated whether non-contrast three-dimensional computed tomography-venography (3DCTV) using 128-row multidetector computed tomography (MDCT) could be the first-choice diagnostic imaging modality for the treatment of varicose veins. Its utility was assessed in terms of estimation of the venous function, ability to visualize incompetent perforators, association with deep venous diseases, and determination of surgical procedures in 1348 patients with 2696 limbs who underwent non-contrast 3DCTV between September 2009 and August 2013.A positive correlation was observed between the diameter of the great saphenous vein and the venous filling index (r = 0.539). The detection rate of incompetent perforators was 86.7%. In deep venous incompetence and deep venous thrombosis, a characteristic finding showing a wide net-like spread of varicose veins from a branch not communicating with the saphenous vein was observed. Non-contrast 3DCTV facilitated an objective understanding of the overall three-dimensional images of varices and was useful for determining surgical strategies. Although the concomitant use of duplex scan is necessary for assessment depending on the situation, it appears that non-contrast 3DCTV could be the first-choice diagnostic imaging modality. (This article is a translation of Jpn J Phlebol 2014; 25: 332-9.)
Objective: To clarify the histopathological characteristics of deep vein thrombosis (DVT) resulting in lethal pulmonary thromboembolism (PE).Subjects and Methods: We investigated 100 autopsy cases of PE from limb DVT. The distribution and chronology of DVT in each deep venous segment were examined. Venous segments were classified into three groups: iliofemoral vein, popliteal vein and calf vein (CV). The CV was subdivided into two subgroups, drainage veins of the soleal vein (SV) and non drainage veins of SV.Results: Eighty-nine patients had bilateral limb DVTs. CV was involved in all limbs with DVT with isolated calf DVTs were seen in 47% of patients. Fresh and organized thrombi were detected in 84% of patients. SV showed the highest incidence of DVTs in eight venous segments. The incidence of DVT gradually decreased according to the drainage route of the central SV. Proximal tips of fresh thrombi were mainly located in the popliteal vein and tibioperoneal trunk, occurring in these locations in 63% of limbs.Conclusions: SV is considered to be the primary site of DVT; the DVT then propagated to proximal veins through the drainage veins. Lethal thromboemboli would occur at proximal veins as a result of proximal propagation from calf DVTs.
Objective: To describe the distribution of ankle-brachial index (ABI) among Japanese cardiovascular inpatients and to explore risk factors of peripheral arterial disease (PAD) associated with ABI ≤0.9.Materials and Methods: This study was a retrospective analysis using clinical record databases of patients with cardiovascular disease admitted to the Department of Cardiovascular Medicine, Kumamoto University Hospital between 2007 and 2014.Results: Of 3639 patients included in the analysis, male patients accounted for 62.1% and the mean age of patients was 66.1 years. Ischemic heart disease (IHD) was observed in 49.1%. ABI ≤0.9 was observed in 11.3% of all patients, 14.1% in the IHD group and 8.5% in the non-IHD group. Age of ≥65 years (odds ratio [OR]: 2.93, 95% confidence interval [CI]: 2.22–3.86), current smoking (OR: 2.28, 95%CI:1.71–3.04), diabetes (OR: 2.15, 95%CI:1.71–2.71), hypertension (OR: 1.42, 95%CI:1.12–1.81) and chronic kidney disease (OR: 2.52, 95%CI:1.82–3.48) were significantly associated factors with ABI ≤0.9.Conclusions: This study suggests that PAD is prevalent even in patients without IHD. Active management of risk factors, early detection of PAD based on ABI, and therapeutic intervention could be effective in preventing future cardiovascular events or death.
Objectives: To study the immediate impact of manual lymph drainage (MLD) on skin and subcutaneous tissue strains in legs with lymphedema using free-hand real-time tissue elastography (RTE).Methods: Skin and subcutaneous tissue strain measurements were taken at the middle of the inner thigh and calf by RTE in 20 legs with lymphedema of 18 patients (stage II: 11, late stage II: 7, stage III: 2) and in 70 legs of 35 normal subjects. In patients with lymphedema, the same measurements were repeated immediately following MLD.Results: Significant negative correlations were found between pre-MLD strains and the MLD-induced changes in thigh and calf skin strains (thigh skin: p <0.01, calf skin: p = 0.05), but not in subcutaneous tissue strains. Pre-MLD intercepts of these regression lines were closer to normal values as compared to mean pre-MLD values (normal thigh skin: 0.54% ± 0.30%, calf skin: 0.25% ± 0.18%, Pre-MLD thigh skin: 0.39% ± 0.20%, calf skin: 0.17% ± 0.12%, Pre-MLD intercept of thigh skin: 0.48%, Pre-MLD intercept of calf skin: 0.31%).Conclusions: It appears that MLD did not simply soften the skin, but rather normalized it in terms of strain. However, this was not confirmed in the subcutaneous tissue.
Purpose: To report the incidence, clinical importance and management of the incompetent gastrocnemius vein.Methods: The incompetency was examined by duplex and pulse-Doppler ultrasound at the popliteal fossa in a standing position between July 2006 and August 2014.Results: Among 1805 legs surveyed, 14 legs showed primary incompetent gastrocnemius vein (0.78%). The incompetency was in medial gastrocnemius vein in 13 legs (93%). Clinical manifestation was varicose vein in the small saphenous territory in nine, varicose vein in great saphenous territory in one, congestive dermatitis in two, calf clamp in one and no symptom in one. The nine cases with varicose vein in the small saphenous territory received surgical management. These included three cases with residual varicose veins after saphenopopliteal disconnection and stripping small saphenous vein. The root of the gastrocnemius vein was divided leaving no complication. In cases without varicose vein in small saphenous territory, an elastic compression socks was useful in some degree.Conclusions: Incompetency of gastrocnemius vein was not so rare. When a case is accompanied by small saphenous varicose veins, division of the root of gastrocnemius vein along with small saphenous vein stripping is recommended in order to reduce residual varicose vein.
Objective: This study aimed to clarify long-term mortality and its predictors in patients with abdominal aortic aneurysm (AAA) who underwent endovascular aneurysm repair (EVAR).Materials and Methods: Patients with AAA who underwent elective EVAR at Tokyo Medical and Dental University hospital between 2008 and 2011 were reviewed. The patients’ data were retrospectively collected from medical records.Results: Sixty-four patients were identified for this study. In long-term follow-up, the survival rate was significantly lower in patients with high preoperative C-reactive protein (CRP) levels. Patients with obstructive lung disease (FEV1/FVC <70%) or anemia tended to have a poorer prognosis but the association was not statistically significant. Age, concurrent hyperlipidemia, and blood pressure levels were not predictors of mortality rates.Discussion: High CRP level, COPD, and anemia reflect inflammation, which is associated with the pathogenesis of AAA. These inflammatory markers are predictors of long-term mortality after EVAR for AAA as well as for other diseases.Conclusions: A high preoperative CRP level was a predictor of increased long-term mortality in patients with AAA who underwent EVAR. No specific leading causes of death were identified for this increase in the mortality rate.
A 73-year-old man was transferred for treatment of abdominal aortic aneurysm. He had no history of abdominal surgeries. Grafting between the infra-renal abdominal aorta and the bilateral common iliac arteries was performed. Proximal and distal cross clamps were applied for grafting. He developed chylous ascites on the 5th post-operative day, 2 days after initiation of oral intake. Fortunately, he responded to treatment with total parenteral hyper-alimentation for 10 days, followed by a low-fat diet. There was no recurrence of ascites.
The prognosis of uncorrected aortic coarctation is poor due to development of heart failure. We performed an on-pump beating heart extraanatomical ascending-descending aortic bypass using a beating heart positioner in an adult with coarctation complicated by severe left ventricular hypertrophy. A 51-year-old woman was referred with severe hypertension. Computed tomography demonstrated severe distal aortic arch narrowing. Coarctation of the aorta was diagnosed. A posterior pericardial beating heart extraanatomical bypass via median sternotomy was performed from the ascending to descending aorta using a heart positioner. Her postoperative course was uneventful and blood pressure was normal on a low-dose beta-blocker.
A 37 year old man known to have inferior vena cava agenesis, presented to our center with severe symptoms of pelvic venous congestion. Surgical approach was attempted by creating a bypass between the right external iliac vein and the portal vein using an autogenous venous bypass (superficial femoral vein). Over a three year follow up, the bypass remained patent with complete resolution of symptoms. The ilio-portal venous bypass suggests a surgical alternative that has not been previously described.
A 51-year-old female with dilated cardiomyopathy underwent a cardiac catheterization via right common femoral vein and artery. Prolonged compression with a bandage and extension of supine bed rest were needed. Immediately after standing up, she lost consciousness and developed electromechanical dissociation. The echocardiogram revealed a huge thrombus filling the main pulmonary trunk and massive enlargement of right ventricle, which suggested acute pulmonary thromboembolism (PTE). Images of computed tomography taken 2 months later detected a huge venous aneurysm of the right popliteal vein. Prolonged compression at the groin area might enhance blood stasis of the ipsilateral popliteal venous aneurysm, followed by life-threatening PTE.
We report a case of femoral arterial bleeding complicated with hemorrhagic shock caused by bacterial infection attributed to an inguinal lymph node metastasis of carcinoma of unknown primary. Because of severe preoperative condition, a venous patch plasty of ruptured artery, and omentopexy for the groin was performed as a less invasive surgery. But the recurrence of bleeding was occurred postoperatively.A staged operation, hemostasis with a venous patch plasty at a first stage, and an extra-anatomical bypass soon after improvement of shock condition in a second stage, can be one of surgical procedures to save the lives and salvage limbs.
A 69-year-old female with Cowden syndrome presented with pain at rest in the right leg. Arteriovenous malformations (AVMs) of the right lower extremity were detected by computed tomography and magnetic resonance imaging. Angiography indicated arteriolovenous fistulae, which were initially treated using a transarterial approach with minimal therapeutic effect. In contrast, excellent outcomes were achieved with a transvenous approach using coil embolization and liquid sclerotherapy for the venous component of the nidus. At 15 months after embolosclerotherapy, no angiographic evidence of AVM recurrence was noted. Embolosclerotherapy by the transvenous approach for AVM in Cowden syndrome was a useful therapeutic strategy for arteriolovenous fistulae.
Surgical treatment of an infected abdominal aortic aneurysm (IAAA) is difficult and the ideal graft material is a subject of debate. A 60-year-old man with untreated diabetes mellitus was referred to our hospital presenting with fever and left lower abdominal pain. The patient was diagnosed with an IAAA by blood culture and computed tomography. We treated the patient surgically for the IAAA using bilateral reversed superficial femoral veins which were shaped into a bifurcated graft. No signs of recurrent infection or aneurysmal dilation were observed for 3 years after the procedure.